Cardiorenal Syndrome in the Hospital

Abstract

The cardiorenal syndrome refers to a group of complex, bidirectional pathophysiological pathways involving dysfunction in both the heart and kidney. Upward of 60% of patients admitted for acute decompensated heart failure have CKD, as defined by an eGFR of <60 ml/min per 1.73 m2. CKD, in turn, is one of the strongest risk factors for mortality and cardiovascular events in acute decompensated heart failure. Although not well understood, the mechanisms in the cardiorenal syndrome include venous congestion, arterial underfilling, neurohormonal activation, inflammation, and endothelial dysfunction. Arterial underfilling may lead to activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, leading to sodium reabsorption and vasoconstriction. Venous congestion likely also mediates and perpetuates these maladaptive pathways. To rule out intrinsic kidney disease that is distinct from the cardiorenal syndrome, one should obtain a careful history, review longitudinal eGFR trends, assess albuminuria and proteinuria, and review the urine sediment and kidney imaging. The hallmark of the cardiorenal syndrome is intense sodium avidity and diuretic resistance, often requiring a combination of diuretics with varying pharmacological targets, and monitoring of urinary response to guide escalations in therapy. Invasive means of decongestion may be required including ultrafiltration or kidney RRT such as peritoneal dialysis, which is often better tolerated from a hemodynamic perspective than intermittent hemodialysis. Strategies for increasing forward perfusion in states of low cardiac output and cardiogenic shock may include afterload reduction and inotropes and, in the most severe cases, mechanical circulatory support devices, many of which have kidney-specific considerations.

From heart failure and kidney dysfunction to cardiorenal syndrome: TMAO may be a bridge

“…CRS is a clinical syndrome involving complex pathophysiological pathways and dysfunction of both the heart and kidneys (McCallum and Sarnak, 2023). Recent studies have shown that CRS is associated with high morbidity and mortality in patients with acute or chronic HF or CKD (Kim et al, 2023).…”

Therapie der Herzinsuffizienz bei chronischer Nierenerkrankung

“…dialysepflichtiger) Niereninsuffizienz und der Notwendigkeit zur intensivmedizinischen Versorgung bedarf eigener Überlegungen zu den Themen hämodynamischer Support, Regulation des Wasserhaushalts und ggf. apparativer Unterstützung vitaler Funktionen 3 .…”

An Updated Review of the Management of Chronic Heart Failure in Patients with Chronic Kidney Disease

“…There are specific challenges with the use of diuretics in patients with HF and CKD. Many patients with CKD have renal sodium affinity, leading to diuretic resistance [ 38 ]. There are several mechanisms which may explain this, including albuminuria and hypoproteinaemia, leading to an increased volume of distribution of the diuretic and reduced delivery to the kidney [ 39 ].…”

“…A diuretic-associated increase in creatinine which is associated with signs of decongestion may represent effective diuresis [ 43 ], and as shown in the Diuretic Optimization Strategies Evaluation (DOSE) study, worsening renal function in this context can paradoxically be a positive prognostic indicator [ 44 ]. However, a rising creatinine with no improvement in signs of congestion is a poor prognostic marker [ 38 ].…”